This document summarizes the key findings from a global meeting on myopia held in 2015. It discusses the definition and prevalence of myopia, which is increasing worldwide and projected to affect half the global population by 2050. High myopia can lead to vision threatening conditions like myopic macular degeneration. Near work and less time outdoors are associated with increased risk of myopia progression. Controlling progression through increased outdoor time, reduced near work, and treatments like low-dose atropine and multifocal lenses may help reduce risks of vision impairment. More research is still needed on causes and management of myopia, especially high myopia.

1. THE IMPACT OF MYOPIA
AND HIGH MYOPIA
Report of the Joint World Health Organization–Brien Holden Vision Institute
Global Scientific Meeting on Myopia

2. Citation
The impact of myopia and high myopia: report of the Joint World Health
Organization–Brien Holden Vision Institute Global Scientific Meeting on Myopia,
University of New South Wales, Sydney, Australia, 16–18 March 2015. Geneva: World
Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.
© World Health Organization 2017
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3. Myopia
• Aristotle (384-322 BC)
Credited with first distinguishing myopia
• Galen (131-201 AD)
Derived the term ‘myopia’
• Myopia=myein (“too close”) and ops (“eye”)
• Results when an eye has excessive refractive power for its
axial length.
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4. 4Impact of Myopia and High Myopia

5. Global prevalence of myopia
• Global Burden of Disease Estimates: URE the leading cause of
moderate and severe vision impairment (53%) and the second
largest cause of blindness [1].
• 2010: Myopia and high myopia were estimated to affect 27% (1893
million) and 2.8% (170 million) of the world population [2].
• Prevalence : Highest in East Asia (approx. 50%) and lower in
Australia, Europe and north and south America.
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6. Figure 1: Numbers of cases (blue) and prevalence (red) of myopia
worldwide between 2000 and 2050
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7. Figure 2 : Numbers of people worldwide with high myopia
(blue) and prevalence (red) between 2000 and 2050
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8. The WHO Projections 2050
• 2050: Prevalence will be ≥ 50% in 57% of the countries, if current trends
continue.
• 2050: Countries in which the prevalence of myopia has been estimated
and measured as low in the past (e.g. India) will have major increases.
• 2050: Myopia will be much higher in high-income regions of the Asia-
Pacific, in east Asia and in south-east Asia
• 2050: About 30% of Africa will be similar to that in Asia today.
• 2050: The prevalence of high myopia is predicted to increase to 24% in all
the Global Burden of Disease regions
Footnote: The WHO model for projections was based on regional structure
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9. Terminology
• Myopia
“a condition in which the spherical equivalent objective
refractive error is ≤ –0.50 dioptre (D) in either eye”.
• High myopia
“a condition in which the spherical equivalent objective
refractive error is ≤ –5.00 D in either eye”.
.
Examples: 1. -2.00/-6.00 x 180
2. +2.00/-6.00 x 180
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10. Pathologic myopia
• Clinical Definition: Not well defined, with different descriptions
across studies of vision-threatening changes in the retina or the
presence of posterior staphyloma, and various criteria for axial
length and spherical equivalents refractive error.
• Acceptable definition: High myopia with signs of retinal atrophic
changes (5).
• Approximately 1% of whites and 1–3% of Asians
• Causes more VI or blindness in Asians (0.2–1.4%) than in
Caucasians (0.1–0.5%)
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11. Myopic macular degeneration (MMD)
• Clinical definition: A vision-threatening condition in people with
myopia, usually high myopia, which comprises diffuse, patchy
macular atrophy with or without lacquer cracks, choroidal
neovascularization and Fuchs spot.
• It was agreed that the direct ophthalmoscope lens power wheel
should be used in rapid assessments.
• Currently, choroidal neovascularization in MMD is managed by
treatment with anti-VEGF.
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12. Myopic macular degeneration
Source: Hayashi et al [33]
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13. Progression of MMD in a group of people
with high myopia (≤ -8.00)
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14. A proposed international photographic classification
and grading system for MMD
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Footnote: No universal grading system for MMD is in use clinically.

15. WHO recommendations for care and
management of pathologic myopia
1. Pathologic myopia: Patient should have access to a full range of eye-care
services.
2. For myopic CNV: Anti VEGF may be considered, but the long-term
prognosis for vision is unknown.
3. Increased risk for glaucoma: Glaucomatous optic neuropathy should be
investigated.
4. Increased risk of RD and cataract: Fundus and anterior segment
examination is essential.
5. If VI is uncorrectable: Patient should have access to comprehensive eye-
care services, including vision rehabilitation and appropriate devices and
surgery if necessary.
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16. Impact of myopia
1. Myopia as a cause of VI and blindness
• Under corrected myopia: The most common cause of VI, as judged by
presentation for poor visual acuity.
• Uncorrected myopia as low as –1.50 D will result in moderate VI, and
uncorrected myopia of –4.00 D can cause blindness [36].
• MMD: The most common cause of VI in myopia. 10% of people with
pathologic myopia develop MMD (due to choroidal neovascularization),
which is bilateral in 30% of cases [16].
• Myopia: Associated with higher risks of glaucoma and cataract but may be
protective against ARMD and DR.
• High myopia: Can cause serious, sight-threatening retinal damage.
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17. 2. Economic Implication
• Global loss of productivity due to URE: I$ 269 billion per annum [14]
• Estimated cost of addressing the problem : US$ 28 billion over 5 years [15]
• Expected 4.9-fold increase in high myopia by 2050.
• The cost of care is also likely to increase significantly.
Singaporean Study [37-38]
• The annual direct cost of optical correction of myopia for Singaporean adults has
been estimated at US$ 755 million.
• The direct cost of myopia in Singaporean children was US$ 148 per child per year.
• If the available data were extrapolated to all cities in Asia, the estimated direct
cost would be US$ 328 billion.
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18. 3. Impact on quality of life and personal development
• Adolescents with myopia: Reported lower scores for total quality of
life, psychosocial functioning and school functioning [39].
• Correction of refractive errors by the provision of spectacles in low
socioeconomic areas markedly improve educational outcomes [40].
• The major contributors to the burden of eye disease at the global
level are refractive errors (27.7 million DALYs) followed by cataract
(17.7 million DALYs) [20].
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19. 3. Burden on global eye care services
Increased prevalence of high myopia
Increase in pathologic myopia
increased VI and blindness
Increased burden on ophthalmological and low-vision services.
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20. Evidence for causes of myopia
1. Optical and environmental influences
• Several optical and environmental factors have been identified as
possible causes of the onset and progression of myopia, acting
either individually or in combination.
1.1 Peripheral hyperopic defocus
• The pattern of peripheral refraction varies with central refraction
(43,44).
– Myope: Have relative hyperopia in the periphery, can increase
ocular growth
– Hyperope: Have relative myopia in the periphery, can cause
slow axial elongation
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21. Association between central and
peripheral refraction
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22. 1.2. Intensive near work (45,46):
• The mechanism by which near work increases axial length is the
combined influence of biomechanical factors (i.e. extraocular
muscle forces, ciliary muscle contraction) associated with near tasks
in downward gaze.
1.3.Time spent outdoors (47):
• Epidemic of myopia in East Asia is primarily due to changes in
environmental (social) factors, specifically intensive education and
less time spent outdoors.
• Observed seasonal variation in the progression of myopia adds
weight to the argument that time spent outdoors slows the
progression of myopia.
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23. Five-year risk of incident myopia among six-year-old
Australian children
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24. (Dashed lines =
Mechanical Tension
Theory;
Dotted lines =
Accommodative
Lag Theory;
Solid line = common to
both theories)
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25. • Genetics and parental history
• Genetics and the environment play a role in the development and
progression of myopia, but the genetic contribution is considered small.
• There is consensus that genes may determine susceptibility to
environmental factors (50).
• The rapid increase in the prevalence of myopia seen over a short time in
east Asia (54, 55, 56) cannot be explained by genetics.
• In the twin study by He et al., baseline refraction and parental myopia
were found to be risk factors.
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26. Control of Myopia
1. Optical control
1.1 Spectacle methods
• Leaving myopia uncorrected: Does not reduce the rate of progression (65).
• Undercorrection: Shown to increase myopia progression.
– Due to peripheral and central blur, stimulating axial growth
• Progressive addition lenses: Have a small, statistically significant effect.
The reduction is correlated with the degree of relative myopia produced in the
superior retina by near addition (69).
• Executive bifocals: with a +1.50 addition and 3 D base-in prism reduced the rate of
myopia progression by 57% (62).
– Reduces the stimulus for axial elongation.
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27. 1.2 Contact lens methods
• Standard RGP: Do not reduce the rate of myopic axial elongation.
• Bifocal contact lenses: Reduced progression (spherical equivalent of
refractive error and axial length).
– Act by reducing accommodative lag (73)
• Orthokeratology: Consistent reduction in myopia progression of
approximately 45% over a two-year period and 30% over five years, when
measured in terms of axial length (63).
• Extended depth-of-focus lenses: Support the myopic defocus hypothesis
(76).
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28. 2. Time spent outdoors and behavioural influences
• Evidence is emerging that spending more time outdoors can protect against the
onset of myopia.
• Sufficient time outdoors (more than two hours/day): Reduced the risk of myopia,
even when they had two myopic parents and continued to perform near work
(77).
– Indoors playing sports not beneficial.
– The nature of the outdoor activities does not seem to be critical (77).
• The mechanism of action of time spent outdoors remains unknown and requires
further investigation.
– Hypothesized that the sunlight stimulates the release of dopamine from the retina, which inhibit
axial elongations (81, 82).
– Seasonal differences: Progression is faster in winter and slower in summer (83).
• Outdoor activity could be made part of obesity reduction campaigns for children,
and schoolchildren in particular.
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29. 3. Pharmacological and therapeutic control
• 3.1 Atropine
• Atropine reduces myopia progression in children in a dose-related manner,
but a rebound effect (“catch-up”) occurs with higher doses (85).
• Atropine at 0.01% :
– Lower doses, 0.01% , reduce the common side-effects observed with the
higher dose.
– Resulted in a 59% reduction in the rate of progress of myopia, with minimal
adverse effects; however, controversially, it had no effect on axial elongation
(85).
– Recently approved by the FDA for long-term amblyopia therapy in children.
– Currently no regulatory approval for the use of atropine to slow myopia
progression
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30. Clinical guidelines for children aged 6–10 years with myopia >
1.0 D and documented myopia progression > 0.5 D per year
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• Clinical guidelines are needed on who should be treated, when treatment
should begin and cessation and the duration of treatment.

31. 3.2 7–methylxanthine
• A non-selective adenosine antagonist.
• Affects the release of neurotransmitters such as dopamine,
norepinephrine, acetylcholine, glutamate and serotonin (86).
• Danish Study
– 8-years of follow-up of 750 myopic reported no side-effects.
– Dose of 400 mg twice a day reduced myopia progression by 60% (70).
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32. Recommendations for myopia control
1. Access to correction: Essential to avoid VI.
2. Full correction of myopia
3. More outdoor activities
3. Less near work
4. Contact lenses and ortho-k
5. PALs
7. Low-dose atropine
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33. Research
• There is a large body of research on myopia.
• However, few areas requires further research:
– Epidemiology of myopia
– Myopigenesis, environmental, optical and therapeutic factors
– Risk factors and individual heterogeneity
– High myopia, pathologic myopia and comorbid conditions
– Eye examinations in myopia
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34. Key messages
• On the basis of current estimates and demographic trends, myopia is the
main cause of distance refractive error and will probably continue to be so
in the future.
• If the increasing prevalence of myopia is not addressed, a similar increase
in URE can be expected.
• Reducing the rate of myopia progression by 50% could reduce the
prevalence of high myopia.
• On the basis of the evidence, that myopia warrants national and
international synergistic efforts, as the costs and public health implications
are huge and often underestimated [2].
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35. Conclusions
• Documented increases in the prevalence of myopia and high
myopia worldwide are a serious public health concern.
• Data to inform research, clinical practice and public health
policy must be produced urgently.
• Consistent use of international terminology for obtaining
internationally comparable, accurate data on the prevalence
of myopia and high myopia.
• Myopia and high myopia should be included as attributable
causes of vision impairment in epidemiological surveys.
• The term “myopic macular degeneration” should be used to
categorize the blinding retinal diseases associated with high
myopia.
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38. 38
Happy weekend 
Impact of Myopia and High Myopia

39. Regions defined in the WHO Global
Burden of Disease programme
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40. Lag of Accommodation
• Lag of Accommodation: The amount by which the
accommodative response of the eye is less than the dioptric
stimulus to accommodation.
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